| A | B |
|---|
| Actuarial value | the percentage of total average cost for coverage benefits that a plan will cover |
| Explanation of Benefits | document that gives detail of how a claim was adjusted |
| Major medical | coverage that includes treatment for long, high-cost illnesses or injuries |
| PAR provider | provider that enters into a contractual agreement with the carrier and agrees to follow the payer's specific guidelines |
| Medical necessity | when medical services, procedures, or supplies meet these criteria, they are said to be medically necessary or meets the standards of medical necessity. |
| IPA | type of HMO whereby services are provided by outpt's networks composed of individual healthcare providers |
| high-risk pool | individuals who have been denied coverage due to preexisting condition and been without coverage for a period of at least 6 months |
| Utilization review | designed to determine the medical necessity and appropriateness of a requested medical service or procedure |
| Clearinghouse | business entity that specializes in consolidating claims received from providers and transmitting into batches to third-party |
| Comprehensive | combination of both basic and major medical insurance into one plan. |
| Staff model | multi-specialty practice in which healthcare services are provided and owned by HMO |
| Clean claim | claim that has no errors or omissions and can be processed without delay |
| Direct Data Entry | submitting insurance claims directly to a third-party |
| Fee-for Service | insurance company pays all or a portion of the fees for the service provided |
| Patient Information Form | document which patient's record their demographic and insurance information |
| Enrollees | individuals who are members of a manage care plan |
| Creditable coverage | coverage that has been in effect for a period of 63 days or more before enrolling in a new health plan |
| Third-party | Any organization that provides payment for specified coverage's provided under the health plan. |
| Commercial Health Insurance | health insurance paid by business entity other than the government |
| Claim attachements | documents that provide additional information to the claim processor |
| Lifetime Maximum Insurance Cap | limit on the amount of reimbursement for any changes incurred by members |
| Preauthotization | required by most healthcare providers before specific procedures or treatment for a patient. |
| Insurance Cap | amount after insurance will not pay any more for charges incurred for one incident or in any one year |
| Autonomy | Working with direct supervision. |
| Blue Card Program | Program that links independent Blues Plans so that so that members and their families can obtain healthcare services while traveling or working anywhere in the U.S. |
| Capitation | Reimbursement used primarily by HMO’s in which the provider or facility is paid a fixed , per capita amount of each individual |
| Carrier | Claims processors that apply Medicare coverage rules to determine the appropriateness and medical necessity of claims |
| Carve-out | Eliminating a certain specialty of health services from coverage under the healthcare policy. |
| Coinsurance | Type of cost sharing between the insurance provider and the policyholder |
| Consultation | When the PCP sends a patient to another provider (usually a specialist) regarding the patient’s condition. |
| Direct contract model | HMO similar to an individual practice association except that the HMO contracts directly with the individual physicians |
| Electronic Remittance Advice (ERA) | Allows payments to be posted to patients’ accounts automatically, eliminating manual posting of claim payments to both electronic and paper claims. |
| Errata | a list of errors of corrections to be made (in a book) |
| Fiscal intermediary | Commercial insurer or agent that contracts with the US Department of Human Health Services (HHS) for the purpose of processing and administering Part A Medicare claims for the reimbursement of healthcare coverage |
| Grandfathered | A provision in the law the exempts an individual or business entity who is already involved in a regulated activity or business from the new regulations established by law. |
| Grievance | Written complains submitted by an individual covered by the plan concerning claims payment, reimbursement, policies, or quality of health services. |
| Iatrogenic effect | Symptoms or illness in a patient brought on unintentionally by a physician’s activity, manner, or therapy. |
| Manage care | Any system of health payment or delivery arrangemnets in which the health plan attempts to control or coordinate the use of health services |
| Minimum essential coverage | The minimum amount that a “large” employer must provide to its employees under the Affordable Care Act. |
| Network | Interrelated system of people and facilityes that communicate withone another and work together as a unit |
| Open-panel-plan | Plan in which the providers maintain their own offices and identities and see patients who belong to an HMO and patients who do not. |
| Point of Service (POS) | Type of managed care plan that allows ptients either to use the HMO provider or to go outside the plan and use any provider they choose. Also called open-ended HMO. |
| Preferred Provider Organization (PPO) | group of hospitals and physicians that agree to render particular services to a group of people, generally under contract with a private insurer |
| Precertification | Process whereby the provider or hospital notifies a health insurance company of an inpatient admission for coverage of a specific medical service, procedure, or prescription drug. |
| Predetermination | Method used by some insurance companies to find out whether or not a specific medical service or procedure would be covered |
| Referral | Request by a healthcare provider for a patient under hos or her care tobe evaluated or treated or both by another provider, usually a specialist |
| Self-insured | When the employer, not an insurance company, is responsible for the cost of medical services for its employees |
| Specialist | Physican who is trained in a certain area of medicine. |
| Stop loss insurance | Protection from exorbitant medical claim. Often used by self-insured groups. |
| Supplemental coverage | Benefit add-ons to health plans such as vision, dental, or prescription drug use. |
